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OREGON HEALTH AUTHORITY, OFFICE FOR OREGON HEALTH POLICY AND RESEARCH

DIVISION 55

PATIENT-CENTERED
PRIMARY CARE HOME PROGRAM

409-055-0000

Scope

These rules (OAR 409-055-0000
to 409-055-0090) establish the Patient-Centered Primary Care Home (PCPCH) Program
and define criteria and process that the Authority shall use to recognize and verify
status as PCPCHs. The PCPCH is a model of primary care that has received attention
in Oregon and across the country for its potential to advance the “triple
aim” goals of health reform: a healthy population, extraordinary patient care
for everyone, and reasonable costs, shared by all. PCPCHs achieve these goals through
a focus on wellness and prevention, coordination of care, active management and
support of individuals with special health care needs, and a patient and family-centered
approach to all aspects of care. PCPCHs emphasize whole-person care in order to
address a patient and family’s physical and behavioral health care needs.

(1) “Administrator”
means the administrator or designee of The Office for Oregon Health Policy and Research
as defined in ORS 442.011.

(2) “Authority”
means the Oregon Health Authority.

(3) “CHIPRA Core Measure
Set” means the initial core set of children's health care quality measures
released by the Centers for Medicare and Medicaid Services in 2009 for voluntary
use by Medicaid and CHIP programs.

(4) “NCQA” means
National Committee for Quality Assurance.

(5) “Office”
means the Office for Oregon Health Policy and Research.

(6) “Patient Centered
Medical Home (PCMH)” means a practice or provider who has been recognized
as such by the National Committee for Quality Assurance.

(7) “Patient-Centered
Primary Care Home (PCPCH)” means a health care team or clinic defined in ORS
414.655, meets the standards pursuant to OAR 409-055-0040, and has been recognized
through the process pursuant to OAR 409-055-0040.

(8) “Personal Health
Information” means demographic information, medical history, test and laboratory
results, insurance information and other data that is collected by a health care
professional to identify an individual and determine appropriate care.

(9) “Practice”
means an individual, facility, institution, corporate entity, or other organization
which provides direct health care services or items, also termed a performing provider,
or bills, obligates and receives reimbursement on behalf of a performing provider
of services, also termed a billing provider (BP). The term provider refers to both
performing providers and BP(s) unless otherwise specified.

(10) “Program”
means Patient-Centered Primary Care Home Program.

(11) “Program website”
means www.primarycarehome.oregon.gov.

(12) “Provider”
means an individual, facility, institution, corporate entity, or other organization
which provides direct health care services or items, also termed a performing provider,
or bills, obligates and receives reimbursement on behalf of a performing provider
of services, also termed a billing provider (BP). The term provider refers to both
performing providers and BP(s) unless otherwise specified.

(13) “Recognition”
means the process through which the Authority determines if a practice has met the
Oregon Patient-Centered Primary Care Home Standards.

(14) “Recognized”
means that the Authority has affirmed that a practice meets the Oregon Patient-Centered
Primary Care Home Standards.

(15) “Tier” means
the level of Patient-Centered Primary Care Home at which the Authority has scored
a practice.

(16) “Verification”
means the process that Office for Oregon Health Policy and Research shall conduct
to ensure that a practice has submitted accurate information to the Authority for
purposes of Patient-Centered Primary Care Home recognition.

(1) The Program is intended to ensure
that there is a uniform process for recognizing PCPCHs throughout the State of Oregon
in order to support primary care transformation.

(2) The Authority shall recognize
practices as PCPCHs upon meeting defined criteria through the Program.

(3) The Authority shall administer
the Program, including data collection and analysis, recognition, and verification
that a practice meets the defined PCPCH criteria. The Authority may also provide
technical assistance as is feasible.

(4) The Authority may contract
for any of the work it deems necessary for efficient and effective administration
of the Program.

(1) Practices, or other entities on
behalf of the practice, that wish to be recognized as a PCPCH shall submit a PCPCH
Recognition Application electronically to the Authority via the Program’s
online application system found on the Program website or by mail to the address
posted on the Program website. The application shall include the quantitative data
described in OAR 409-055-0040.

(2) The Authority shall review
the application within 60 days of its submission to determine whether it is accurate,
complete, and meets the recognition requirements. If the application is incomplete
the applicant will be notified in writing of the information that is missing and
when it must be submitted.

(3) The Authority shall review
a complete application within 60 days of submission. If the Authority determines
that the applicant has met the requirements of these rules the Authority shall:

(a) Inform the applicant
in writing that the application has been approved as a recognized PCPCH,

(b) Assign a Tier level,
and

(c) Include the effective
recognition date.

(4) The Authority shall maintain
instructions and criteria for submitting a PCPCH Recognition Application posted
on the Program website.

(5) The Authority may deny
PCPCH recognition if an applicant does not meet the requirements of these rules.

(6) A Practice may request
that the Authority reconsider the denial of PCPCH recognition or reconsider the
assigned tier level. A request for reconsideration must be submitted in writing
to the Authority within 90 days of the date of the denial or approval letter and
must include a detailed explanation of why the practice believes the Authority’s
decision is in error along with any supporting documentation. The Authority shall
inform the practice in writing whether it has reconsidered its decision.

(7) Practices submitting
applications on or after September 3, 2013 must apply to renew their recognition
once every two years. Recognition will expire two years from the effective date
of recognition that was issued by the Authority.

(a) At the Authority’s
discretion a 30-day grace period may be allowed for PCPCHs to submit their renewal
application without having a lapse in recognition status.

(b) If a PCPCH believes that
it meets the criteria to be recognized at a higher tier or increase it’s point
threshold by at least 15 points, it may request to have its tier status reassessed
by re-submitting an application not more than once every six months. The Authority
may grant exceptions to the six month time period for good cause shown.

(1) The PCPCH recognition criteria are
divided into “Must-Pass” measures and other measures that place the
practice on a scale of maturity or ‘tier’ that reflect basic to more
advanced PCPCH functions.

(2) Must-Pass and 5 point
measures focus on foundational PCPCH elements that should be achievable by most
practices in Oregon with significant effort, but without significant financial outlay.

(8) Measure specifications,
thresholds for demonstrating improvement, and benchmarks for quantitative data elements
are available on the Program website.

(9) National Committee for
Quality Assurance (NCQA) recognition shall be acknowledged in the Authority’s
PCPCH recognition process; however, a practice is not required to use its NCQA recognition
to meet the Oregon PCPCH standards. A practice that does not wish to use its NCQA
recognition to meet the Oregon PCPCH standards must indicate so during the PCPCH
application process and submit a complete PCPCH application.

(10) A practice seeking Oregon
PCPCH recognition based on its NCQA recognition must:

(a) Submit a PCPCH application
and evidence of its NCQA recognition along with its application;

(1) To be recognized as a PCPCH, a practice
must attest to meeting the criteria and submit quantitative data elements to support
its attestation in accordance with Tables 1 & 2, incorporated by reference.

(2) Quantitative data shall
be aggregated at the practice level, not the individual patient level, and a practice
may not transfer any personal health information to the Authority during the PCPCH
application process.

(3) PCPCHs must submit new
quantitative and attestation data as a part of the recognition renewal process and
must use the specifications found on the Program website for calculating application
data.

(4) If approved by the practice,
other entities may submit information on behalf of a practice, as long as appropriate
practice staff has reviewed all application information and data prior to submission.

(5) A practice may request
an exception to any of the quantitative data reporting requirements in Table 2 or
the Must-Pass criteria by submitting a form prescribed by the program. The Authority
may grant exceptions for good cause shown.

(6) Practices are required
to submit 12 months of quantitative data in order to meet standards 2.A., 4.A. and
4.B. A practice may request an exception to the 12 month data reporting period by
submitting a form prescribed by the program. The Authority may grant exceptions
for good cause shown.

(7) The Authority shall notify
the practice within 60 days of complete application and exception submission whether
or not the requested exception has been granted.

(1) The Authority shall conduct at least
one on-site verification review of each recognized PCPCH to determine compliance
with PCPCH criteria every five years and at such other times as the Authority deems
necessary or at the request of the Division of Medical Assistance Programs (DMAP),
or any other applicable program within the Authority. The purpose of the review
is to verify reported attestation and quantitative data elements for the purposes
of confirming recognition and Tier level.

(2) PCPCHs selected for verification
shall be notified no less than 30 days prior to the scheduled review.

(3) PCPCHs shall permit Authority
staff access to the practice’s place of business during the review.

(1) If the Authority finds that the
practice is not in compliance with processes as attested to, the Authority shall
issue a written warning requiring the practice to submit an improvement plan to
the Program within 90 days of the date of the written warning. The improvement plan
must include a description of the practice’s plan and timeline to correct
the deficiency and proposed documentation or other demonstration that would verify
the practice is in compliance.

(2) Authority will review
the improvement plan and any documentation the practice submits in accordance with
the deficiency, and if remedied, no further action will be taken.

(3) If a practice fails to
submit the improvement plan or move into compliance within 90 days of the date of
the written warning, the Authority may issue a letter of non-compliance and amend
the practice’s PCPCH recognition to reflect the appropriate Tier level or
revoke its PCPCH status.

(4) If the Authority amends
a practice’s tier level or revokes PCPCH status this information will be made
available to DMAP, the coordinated care or managed care plans, and insurance carriers.

(5) A practice that has had
its PCPCH status revoked may have it reissued after reapplying for recognition and
when the Authority determines that compliance with PCPCH Standards has been achieved
satisfactorily.

(6) In order for the Authority
to receive federal funding for Medicaid clients receiving services through a PCPCH,
documentation of certain processes are required by the Centers for Medicare and
Medicaid Services. Documentation requirements can be found in OAR 410-141-0860.
If non-compliance is due to lack of service documentation required per OAR 410-141-0860,
a referral may be made to the DMAP.

(7) If the Authority finds
a lack of documentation per OAR 410-141-0860 to support the authorized tier level,
the Authority may make a referral to the DMAP and may conduct an audit pursuant
to the standards in OAR 943-120-1505.

(3) The Authority shall develop a system for making recognized
PCPCH practice names available to the general public through the Program website.

(4) Practices who do not wish to have their
name listed on the publicly available list should send an e-mail to PCPCH@state.or.us
with the title “opt-out” in the subject line within 10 business days
of receiving confirmation of Tier status per OAR 409-055-0040.

(1) One objective of these standards
is to facilitate appropriate reimbursement for PCPCHs consistent with their recognized
Tier levels. The standards and Tier recognition process established in this rule
are consistent with statutory objectives to align financial incentives to support
utilization of PCPCHs, in recognition of the standards that are required to be met
at different Tiers.

(2) Managed care plans and insurance
carriers may obtain from the Authority the Tier level recognition of any practice.

(3) Within applicable programs,
the Authority shall develop and implement reimbursement methodologies that reimburse
practices based on recognition of Tier level, taking into consideration incurred
practice costs for meeting the Tier criteria.

The official copy of an Oregon Administrative Rule is
contained in the Administrative Order filed at the Archives Division,
800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the
published version are satisfied in favor of the Administrative Order.
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